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Walk the talk on welfare and well-being

February-March 2018

The year is now well underway and hopefully the New Year’s resolutions you made are on track. I must confess I did not make any resolutions this time (after a history of failing to maintain them) and just enjoyed the break.

I have reflected on the issues for New Zealand anaesthesia this year and believe these are:

  • Name change of our specialty. To me a no brainer so will not spend any more of my word count on this topic, apart from to encourage you to think, discuss and participate in the vote later this year. I would encourage you to read the article in our December magazine which outlines the issues around this topic.
  • Climate change: A big issue which concerns all members; lucky for us some are extremely passionate and will motivate the rest of us. With the help of some of our members we have written a submission on your behalf to ANZCA in response a new professional document on this topic – PS64. Watch this space for more on this issue.
  • Welfare: I would like to focus on this again in this blog. I have referred to destructive behaviour in a previous blog. The recent death of a colleague in Whangarei brought this to the fore for me. His wife has written very candidly about this. (1)

So, Welfare:

I find this a fascinating subject and one that brings out an incongruity in our approach. We can read, talk and acknowledge the importance of this topic but not live by the principles inherent to good welfare. The nursing fraternity seems to have the same problem. Interestingly, the police (in NZ at least), our psychology colleagues, and the military are miles ahead of us on this one. The psychologists have recognised the importance of a formal peer relationship and debrief, which they have packaged into protected time as “supervision.” Arguably, not the best label but one that enables a paid for peer to engage in peer discussion about any topic that the mentee wishes to discuss. I understand this usually relates to clinical matters, but any subject is fair game – e.g. children, marriage, personal growth etc.
The police are required to have a regular session with a counsellor, thus building up a stable and trusting relationship so that when the chips are down the professional support is already established. If a police officer in New Zealand is subject to a critical event (a shooting as an extreme example) they are stood down until debriefed and deemed fit to return. The military has a buddy system. You are assigned a buddy: you watch their back and they watch yours.

I contrast these support systems with my experience as a provisional fellow. A patient exsanguinated during a mediastinoscopy, complicated by a laceration to a pulmonary vein. The only acknowledgement of an emotionally critical event was the surgeon asking how much delay was required before sending for the next patient.
The College has recently engaged an SOS counselling service.  While this has some value no doubt, I would argue that this is by no means sufficient and that we should be encouraging a more formalised approach as just described.
On a more positive note, at least we are now acknowledging that there is an issue regarding welfare and wellbeing. The College is convening a workshop on welfare in mid-February to which I have been invited. I am excited by this and hopeful that we will be able to have some impact on the health of our anaesthetic community. Consequently, I have been reading about the topic – thankfully there is a tonne of literature. I have stumbled across a recent UK publication (2) which addresses this. Much of the book is directed at leadership style, which is NOT what I want to address. However, it is also about well-being and culture which are both very topical right now.  These topics are interwoven. The Medical Council of New Zealand (MCNZ) is promoting cultural awareness in the broadest sense of the term, which I fully endorse. I have encouraged the College to incorporate these concepts into our CPD. I quote from an old MCNZ document:

“Cultural mores identified by the Council are not restricted to ethnicity, but also include (and are not limited to) those related to gender, spiritual beliefs, sexual orientation, lifestyle, beliefs, age, social status or perceived economic worth.“ (3)

One of the many things that struck me when reading the above-mentioned book are the many internal and external tensions we constantly deal with, either consciously or subconsciously. In medicine and nursing we talk the talk but don’t walk it. It is in our work environments also. Leaders and managers talk about a culture of innovation and creativity and how this leads to enhanced organisational performance and encourages “discretionary effort” – altruism or going the extra mile. However, the reality is a culture of standardisation and rules in which creativity and autonomy are not encouraged and, are even seen as disruptive.  The extreme version of this is known as Taylorism, in which rigid supervisory regimes are championed. Clearly in complex work environments, such as those in which we function, there needs to be a degree of Taylorism. So how do anaesthesiologists as perioperative leaders balance Taylorism with creativity and innovation? This is a tough one; I confess I struggle with the current rigid approach to perioperative processes which seem to sacrifice efficiency for process regardless of the cost.  For me, and many others, a tension results. If this tension is not recognised and managed it impacts on both our personal and work lives. There are various ways of measuring this which the book goes into in some detail; it discusses absenteeism, leavism and presenteeism. The ASMS refer to these concepts also. There is also long-term psychological damage which is harder to measure but significant and very common. I quote:

“It appears that even well-educated, healthy, economically comfortable older adults face significant challenges in their efforts to maintain a sense of purpose and self-realisation in later life.” – Carol Ryff., who draws from the writings of Carl Jung (personality types) and Abraham Maslow (hierarchy of needs) which you may remember from medical school.

This is against a background of increasing rates of depression and anxiety that a renowned child psychiatrist (4) attributes to changes in our social structure that have adversely impacted on the neuro sequential development of our brains. In particular a tendency to move away from large extended family groups which provide a much more supportive and nurturing environment for the emotional and social development of children.

To add to this, we are consistently subject to the pressure of actual or potential complaints and expected to continue performing as if such stress were normal and not distracting. I am hopeful that at some stage this year Jennifer Woods (ANZCA NZNC Chair) and I, will be able to discuss this with the current Health and Disability Commissioner.

 

At this point many may be thinking that this is soft stuff and promoting a nanny culture, again, reflecting the tensions we experience.

So, what is psychological well-being? This can be divided in two, and I believe the second one is where we should focus:

  • Hedonic, or feeling good.
  • Eudaimonic or having meaning and purpose.
    • Self-acceptance, or positive evaluation of one’s past life
    • Personal growth, or sense of continual growth and development
    • Purpose in life, or belief that one’s life is purposeful and meaningful.
    • Positive relationships with others or quality relations with others. (Self- explanatory)
    • Environmental mastery, or capacity to manage one’s life and surrounding world.
    • Autonomy, or a sense of self-determination.

Ways to promote psychological well-being include:

  • Resilience, a trendy topic but also controversial and not regarded as useful by some of the experts. In essence optimising resilience where possible; and if not possible recognising and accepting it.
  • Creating the right environment, so this is about culture, identity, the organisational paradigm and promoting “engagement,” yet another trendy term.
  • Alignment of leaders; perhaps a tired concept. This text breaks it down into:
    • Knowing your stuff
    • Knowing your staff
    • Knowing yourself.

So, what is the NZSA’s role in addressing well-being and promoting it? If you have an opinion I would very much like to hear from you. Currently, we have a multifaceted approach:
Advocacy: We can advocate on your behalf, including advocacy to government and health organisations.

Education: We can raise the profile of these issues and promote the available information and resources

Community: Maintain peer support groups such as our networks to counter isolation and provide an avenue for sharing experiences and concerns.

Hopefully, I will have additional ideas following the workshop.

Once again, may the force be with you, David

References:

  1. http://blogs.bmj.com/bmj/2017/12/14/kate-harding-i-have-lost-my-husband-could-not-be-more-accurate-it-feels-like-a-carelessness/
  2. Managing Health and Well Being in the Public Sector. Ian Hesketh and Cary Cooper. 2018. P19.
  3. Medical Council O NZ: Statement on Cultural Competence August 2006.
  4. Bruce Perry. “The Boy who was Raised as a Dog.”